Association between the composite dietary antioxidant index and metabolic dysfunction-associated steatotic liver disease in adults: a cross-sectional study from NHANES 2017–2020

Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as a predominant liver disease worldwide, lacking approved drugs for clinical intervention at present. The composite dietary antioxidant index (CDAI) is used to assess the anti-inflammatory properties of diets, with higher CDAI indicating greater exposure to antioxidants. Therefore, our study aimed to explore the relationship between CDAI and MASLD in order to identify potential therapeutic approaches. We collected data from 12,286 participants in the National Health and Nutrition Examination Survey (NHANES) database from 2017 to 2020 for analysis. The correlation between CDAI and MASLD status, controlled attenuation parameter (CAP), and liver stiffness measurement (LSM) was evaluated by adjusting for confounding variables using weighted binary logistic regression model, linear regression model, and restricted cubic spline (RCS) regression. The median CDAI in this study was − 0.3055 (interquartile range [IQR], − 2.299 to 2.290). The CDAI was higher in the population characterized by being young, female, higher income, absence of diabetes, and non-MASLD. After multivariable adjustment, the results of the weighted linear regression model suggested that higher CDAI may be associated with a decrease in CAP values; the results of the RCS regression model indicated significant non-linear relationships between MASLD status, CAP, LSM, and CDAI. The CDAI corresponding to the inflection points of the relationship curves between MASLD status, CAP, LSM, and CDAI were 0.349, 0.699, and 0.174, respectively. After further stratification by gender, we found that the relationship between MASLD status, CAP, and CDAI was significantly linear for females, whereas for males, it was non-linear, and the CDAI values corresponding to the inflection points in the curves for males were 1.325 and 0.985, respectively. We found that higher CDAI may be associated with decreased CAP values, particularly significant in females, suggesting that the intake of complex dietary antioxidants may ameliorate hepatic steatosis and reduce the occurrence of MASLD. Therefore, promoting dietary patterns rich in antioxidants may be an appropriate strategy to reduce the incidence of MASLD.

complications and chronic liver failure have a 5 to tenfold increased risk of mortality 3 .Currently, hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related deaths globally, following lung, breast, and colorectal cancer, however, it is the second leading cause of cancer-related deaths in males 4 .While viral hepatitis remains the primary causative factor for the development of HCC, the rising prevalence of NAFLD-related cirrhosis suggests a potential shift in underlying etiological factors 5,6 .
With the widespread prevalence of obesity, type 2 diabetes mellitus (T2DM), and metabolic syndrome (MetS), the global incidence of NAFLD has increased significantly over the past few decades 7 .A recent meta-analysis estimated that the prevalence of NAFLD among the global adult population was at least 30% between 1990 and 2019, and the estimated prevalence of NAFLD can reach as high as 38.2% when considering data for the period 2016-2019 only 8 .Due to the rapidly increasing global prevalence of MetS-related risk factors and an aging population, it is estimated that the burden of late-stage diseases caused by NAFLD will become even more severe 9 .
NAFLD is a chronic metabolic stress-induced liver injury in genetically susceptible individuals due to longterm nutritional excess 10 .With the global prevalence of obesity and diabetes, the limitations of the exclusive disease diagnosis criteria and stigmatizing terminology associated with NAFLD have become increasingly prominent over the past 40 years.In the past three years, international consensus groups and three major hepatology societies have successively recommended renaming NAFLD as metabolic-associated fatty liver disease (MAFLD) and metabolic dysfunction-associated steatotic liver disease (MASLD) 11,12 .MASLD places a heightened emphasis on the involvement of metabolic cardiovascular risk factors in the progression of NAFLD compared to MAFLD, enabling more precise identification of individuals at an elevated risk of developing diabetes 12,13 .Due to the intricate pathophysiological mechanisms and diverse disease phenotypes observed in NAFLD, there are currently no approved specific drug therapies for its treatment.Improving dietary structure and lifestyle remains the cornerstone of treatment for the majority of NAFLD patients 14 .
Previous studies have shown that dietary-derived antioxidants are critical regulators of lipid homeostasis, metabolism-related protein expression, and activity, which regulate lipid synthesis, lipid oxidation, peroxidation, and inflammation 15 .Vahid F et al. 16 studied the relationship between dietary antioxidant index (DAI) calculated based on vitamins A, C, E, selenium, manganese, zinc, and NAFLD in the Iranian population, and the results showed that consuming the above-mentioned antioxidants through food intake can effectively reduce the incidence of NAFLD.The composite dietary antioxidant index (CDAI) is calculated based on a 24-h recall of dietary intake containing six antioxidants (carotenoids, vitamin A, C, E, zinc, and selenium) 17 .The CDAI and DAI differ in the composition of antioxidants they include, and it is currently unclear whether there are differences in the relationship between CDAI/DAI and the risk of NAFLD among different ethnicities and after the renaming of NAFLD to MASLD.Therefore, in this study, we analyzed the potential association between CDAI and MASLD using the database of the National Health and Nutrition Examination Survey (NHANES), so that we can better understand and treat MASLD.

Study population
The NHANES database primarily consists of five categories of continuous survey data, which comprise demographic information, dietary patterns, examination findings, laboratory results, and questionnaire responses.NHANES, a significant initiative overseen by the National Center for Health Statistics (NCHS), serves the purpose of evaluating the health and nutritional well-being of the American population, encompassing individuals of all age groups, including both adults and children.The survey has been transformed since 1999 into a continuous research program on a two-year cycle, with a nationally representative sample of around 5000 individuals surveyed each year, which effectively captures the health and nutritional profile of the population 18 .In this study, we selected the data from the two most recent cycles of NHANES, 2017-2018 and 2019-2020, because these cycles used Vibration-Controlled Transient Elastography (VCTE) to measure Controlled Attenuation Parameter (CAP) and Liver Stiffness Measurement (LSM) in participants, which can assess the degree of hepatic steatosis and hepatic fibrosis in participants, respectively 19,20 .The data in utilized in this study were sourced from the publicly accessible website of the National Center for Health Statistics, which could not identify the data frame 21 .Ethical approval for this study has been obtained from the NCHS Ethics Review Board, and written informed consent was provided by all participants involved.
A total of 24,814 participants were enrolled in the study over two NHANES cycles from 2017 to 2020.We excluded the following participants: (1) 9168 participants without VCTE assessment of hepatic steatosis and hepatic fibrosis results, (2) 2210 participants with incomplete information that hindered the diagnosis of MASLD, and (3) 1150 participants for whom data was insufficient to calculate CDAI, and ultimately, a total of 12,286 participants were included in the analysis (Fig. 1).All participants in this study were adults aged 18 years or older.

Definition of MASLD
In this study, the diagnosis of MASLD in adults was determined by measuring the Controlled Attenuation Parameter (CAP) using VCTE.Participants were assessed for the presence of hepatic steatosis based on a CAP threshold of ≥ 248 dB/m.If the CAP value exceeded this threshold, it was classified as hepatic steatosis, whereas CAP values below 248 dB/m indicated an absence of MASLD diagnosis 12,22 .For participants with hepatic steatosis, additional criteria were considered to determine their cardiovascular metabolic status.These criteria included: (1) BMI ≥ 25 kg/m 2 or waist circumference > 94 cm (males), > 80 cm (females), or adjusted based on ethnicity, (2) fasting blood glucose ≥ 5.6 mmol/L or 2-h postprandial blood glucose ≥ 7.8 mmol/L or HbA1c ≥ 5.7% or diagnosed with type 2 diabetes or on treatment for type 2 diabetes, (3) blood pressure ≥ 130/85 mmHg or on specific antihypertensive treatment, (4) plasma triglycerides ≥ 1.7 mmol/L or on lipid-lowering therapy, (5) plasma high-density lipoprotein cholesterol ≤ 1.0 mmol/L (males), ≤ 1.3 mmol/L (females), or on lipid-lowering therapy.If any of the above cardiovascular-metabolic criteria were met, it was necessary to check the participant for other etiologies contributing to hepatic steatosis.If no other etiology was present, a diagnosis of MASLD was made, or if other etiologies were present, a diagnosis of MASLD and greater alcohol consumption (MetALD) or a combination with other etiologies was made.If participants didn't have any other cardiovascular metabolic risk factors or other causes of steatosis, it was defined as cryptogenic steatotic liver disease (SLD).If there were no other cardiovascular metabolic risk factors but there were other causes of hepatic steatosis, it was defined as other specific aetiology of SLD 12 .Other causes of hepatic steatosis in this study included (1) excessive alcohol consumption (≥ 2 drinks per day for women, ≥ 3 drinks per day for men, or engaging in binge drinking 2 or more days per month 23,24 ), (2) hepatitis B/C virus infection, (3) use of medications associated with steatosis (e.g., tamoxifen, aspirin, amiodarone, methotrexate, nucleoside reverse transcriptase inhibitors, ibuprofen, valproic acid, carbamazepine, fluorouracil, protease inhibitors, glucocorticoids, irinotecan, etc.), and (4) iron overload.

Evaluation of CDAI
The dietary information for each participant in NHANES was derived from the dietary interview section, which was obtained by the U.S. Department of Agriculture's Food Surveys Research Group by counting food and nutrient intake in the 24 h before the interview for the respondent 25 .All participants underwent two 24-h dietary recall interviews: the initial interview took place at a mobile examination center (MEC), while the second interview was conducted over the phone within 3-10 days.To minimize the impact of memory bias resulting from an extended time gap, we used the data from the first on-site interview to analyze.We used the CDAI previously developed by Wright et al. 26 to assess the relationship between dietary antioxidants and MASLD.The CDAI has been validated in another study using serum inflammatory markers, confirming that it provides a potential method for measuring the anti-inflammatory properties of the diet 27 .Based on the formula developed by Wright et al. 26 , we calculated the CDAI by subtracting the global mean and dividing it by the global standard deviation (SD) to standardize six dietary antioxidants (carotenoids, vitamin A, C, E, zinc, and selenium).Then, the CDAI was calculated by summing up these standardized intake amounts as shown in the following specific formula:

Covariates
To eliminate other confounding factors from interfering with the study results, we also analyzed demographic characteristics (such as age, sex, marital status, education level, race, and economic status), lifestyle factors (such as smoking and alcohol consumption), and underlying diseases (including diabetes, hypertension, dyslipidemia), and relevant medication history collected through the face-to-face interviews.Additionally, relevant examination parameters (including body mass index (BMI), waist circumference, CAP, and LSM) and laboratory test results collected at the MEC were also included in the analysis.During the two NHANES cycles from 2017 to 2020, professionally trained technicians, following the operational manual for liver transient elastography, conducted VCTE using the FibroScan 502 V2 Touch model, which resulted in the measurement of the CAP and LSM values for each participant.For the participants' LSM, a reliable testing result was determined when the interquartile range/median of LSM was ≤ 30% 28 .Based on previous meta-analysis results, we established the threshold of CAP ≥ 248 dB/m as indicative of hepatic steatosis 22 .The optimal LSM threshold for diagnosing liver fibrosis was 6.3 kPa, with LSM ≥ 9.7 kPa defined as progressive liver fibrosis 29,30 .
In this study, race, marital status, educational level, and economic status are shown in Table 1 (the above information was gathered through face-to-face interviews and survey questionnaires).BMI is calculated based on weight and height and is categorized as < 25, 25-30, and ≥ 30 kg/m 231 .Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) = fasting insulin (μU/mL) × fasting glucose (mmol/L)/22.5 32  www.nature.com/scientificreports/glycosylated hemoglobin (HbA1c) levels ≥ 6.5%, or the use of medication for diabetes 33 .Hypertension was defined as mean systolic blood pressure (SBP) ≥ 140 mmHg and/or mean diastolic blood pressure (DBP) ≥ 90 mmHg or self-reported hypertension and taking anti-hypertensive medication.Smoking status was categorized as current smoker, never smoker, and past smoker.Drinking status was determined based on participant self-report questionnaires of the amount and frequency of alcohol consumption 34 .Drinkers are categorized into never drinkers (having consumed alcohol < 12 times in a lifetime); mild drinkers (≤ 1 drink per day for women, ≤ 2 drinks per day for men); moderate drinkers (≥ 2 drinks per day for women, ≥ 3 drinks per day for men, or engaging in binge drinking 2 or more days but less than 5 days per month); heavy drinkers (≥ 3 drinks per day for women, ≥ 4 drinks per day for men, or engaging in binge drinking 5 or more days per month) 23,24 .All routine blood and blood biochemistry tests in the study were performed according to the laboratory/medical technician procedures manual of NHANES 35 .

Statistical analysis
All statistical analyses in this study were conducted using R software (version 4.2.3, http:// www.r-proje ct.org).
The significance of all statistical results was set at P < 0.05, and the significance level was two-tailed.We directly excluded participants with missing values for the exposure variable CDAI and/or the outcome variable MASLD.
For participants with missing values in other covariates, we used the "missForest" 36 R package to impute the missing values by the random forest interpolation method, ensuring that it did not affect the overall analysis results.In the analysis of participants' baseline characteristics, we converted the calculated CDAI into quartiles and assessed statistical differences between quartile groups.Continuous variables in participants' baseline characteristics were expressed using weighted means ± SD and compared using weighted linear regression analyses; descriptions of categorical variables in baseline characteristics were expressed using weighted percentages and compared using the Wilcoxon rank sum test, and statistical analyses were conducted using the "survey" 37 , "rms" 38 R package for statistical analysis.We performed Spearman's test for correlation analysis between continuous variables and generated correlation heatmaps using the "corrplot" 39 R package.To compare multiple independent continuous variables, the Kruskal-Wallis test was employed.Additionally, violin plots were drawn with the "ggpubr" 40 R package.We also used a nonlinear analysis method, restricted cubic spline (RCS), to fit a multiple regression model to investigate the relationship between exposure and outcome variables, which was drawn with the "nhanesR" (https:// github.com/ shaoy ouche ng/ nhane sR), "ggplot2" 41 R package, where the relationship between MASLD status and CDAI was analyzed using a multiple logistic regression model, and the relationship between CAP and LSM, respectively, and CDAI were analyzed using a multiple linear regression model.In the regression analysis of this study, we constructed four models based on different covariates: Crude Model: without adjusting for any covariates; Model I: adjusted for gender, age, and ethnicity; Model II: adjusted for the variables of gender, age, ethnicity, marital status, education level, diabetes mellitus, hypertension, family incometo-poverty ratio (PIR), waist circumference, BMI, smoking, and alcohol use.In addition, we also presented the results of weighted regression and subgroup analyses in a forest plot using the "forestploter" (https:// github.com/ cran/ fores tplot er) R package.

Methods consistency statement
We confirm that all methods employed in this study have been conducted in strict accordance with the relevant guidelines and regulations.The research protocol was designed and implemented with adherence to ethical standards and in compliance with applicable laws and regulations governing the field of study.We ensured the welfare and safety of participants, followed appropriate procedures for data collection, analysis, and interpretation, and maintained the confidentiality and privacy of individuals involved.Our research methodology and practices

Ethics approval and consent to participate
Ethical approvals were granted by the National Center for Health Statistics Ethics Review Committee, and written informed consents were obtained from all participants involved.The protocol descriptions are available at https:// www.cdc.gov/ nchs/ nhanes/ irba98.htm.

Baseline characteristics of participants
We analyzed data from 12,286 participants over 2 NHANES cycles from 2017 to 2020.The weighted mean age of the participants was 47.18 ± 0.46 years, ranging from 18 to 80 years, and the weighted sex ratio of men to women was 49.49% to 50.51%, indicating a slightly higher proportion of women in the study population.The median CDAI in the study population was -0.3055 (interquartile range [IQR], − 2.299 to 2.290).Tables 1 and 2 1, we found that younger individuals (age > = 18, < 60), females, non-Hispanic white, married/cohabiting, with a high school education or above, with a household income above three times the poverty level (PIR > 3), BMI > = 30, without diabetes or prediabetes, mild alcohol consumption, non-smokers, and participants not diagnosed with MASLD had higher CDAI compared to other groups (e.g., older (age ≥ 60 years), unmarried, low educational attainment, other Hispanic, poor, lower BMI, diabetes, smoking, never drink alcohol, and diagnosis of MASLD).

Correlation analysis between dietary antioxidant intake and CDAI with various measurement parameters
Figure 2 analyzes the correlations between CDAI, various dietary antioxidants, anthropometric measurements, and blood biochemistry, which shows the results of significant correlations among these indicators with statistical significance.Our findings revealed a negative correlation between the intake of vitamin A, vitamin E, carotenoids, and CDAI with CAP, waist circumference, GGT, and ALP.In addition, CDAI was also negatively associated with glucose, HbA1C, insulin, and BMI.Vitamin C was only negatively correlated with CAP and waist circumference.Hence, CDAI exhibits a greater capacity in lowering metabolic-related risk indicators compared to a single dietary antioxidant.Additionally, there is a negative correlation between CDAI and participants' CAP value, indicating its potential to mitigate liver inflammation associated with NAFLD.We did not find a correlation between the trace elements zinc, selenium and metabolism-related indicators, nor was there a significant correlation between CDAI, each dietary antioxidant, and LSM.In our study, HDL-C was also negatively associated with glucose, HbA1C, uric acid, insulin, BMI, TG, CAP, and waist circumference.A positive correlation was observed between CDAI and various dietary antioxidants.

Relationship between CAP, LSM, and CDAI among different categories of MASLD
Figure 3 shows the relationship between CAP, LSM, and CDAI among different categories of MASLD.We found that CDAI was not significantly different in all categories of MASLD populations, with p-values > 0.05, whereas the CAP values for each type of MASLD were higher than those for non-MASLD.There was no statistically significant difference in CAP values between MASLD and MetALD or other combination aetiology, but both were higher than CAP values of other aetiology.LSM values of both MASLD (mean: 6.7 kPa) and MetALD or other combination aetiology (mean: 6.8 kPa) types were significantly higher than LSM values of non-MASLD (mean: 5.2 kPa) and other aetiology (mean: 4.9 kPa) types.The mean LSM value for all participants in this study was 6.0 kPa, which is less than the upper limit of normal LSM of 6.3 kPa.; the p-value for the trend was 0.038.The correlation between the highest quartile of CDAI and CAP values exhibited a significantly stronger negative association compared to the lowest quartile of CDAI.Therefore, we believe that higher CDAI may be associated with a decrease in CAP values after controlling for covariates.Similarly, to analyze the relationship between CDAI and LSM values, we found that the p for trend for the crude model, Model I, and Model II were > 0.05 after unadjusted and adjusted for covariates.In Model II, the β (95% CI) values were as follows: Q1: 0.00 (reference), Q2: − 0.440 (− 0.880, 0.001), Q3: − 0.360 (− 0.825, 0.106), and Q4: 0.147 (− 0.275, 0.569), with a p-value for the trend of 0.083, therefore, we conclude that there is no significant correlation between CDAI and LSM values.In addition, in Table 3, we also used four different weighted logistic regression models to analyze the relationship between MASLD status and CDAI.We found that the p for trend for the crude model was > 0.05 when unadjusted for covariates.In Model I, the odds ratio (OR) (95% CI) values were as follows: Q1: 1.00 (reference), Q2: 1.034 (0.834, 1.

Subgroup analyses of MASLD status, CAP, LSM, and CDAI by potential confounders
To verify the reliability of the above results, we further conducted stratified analyses on the correlation between the participants' CAP, LSM, MASLD status, and CDAI, respectively, based on age, gender, race, education level, marital status, PIR, BMI, as well as the presence of diabetes and hypertension (Fig. 4).We found that the association between CDAI and CAP remained consistent regardless of stratum, and after multiple testing corrections, no significant interaction effects were observed between CDAI and CAP across different strata (all P for interaction > 0.05).These suggest that gender, age, race, marital status, education level, PIR, BMI, as well as the presence of diabetes and hypertension do not influence the negative correlation between CAP and CDAI.We also observed a stronger negative correlation between CDAI and CAP in participants who were female, 18 years < age < 60 years, non-Hispanic white, unmarried, without hypertension, and had a BMI > 30 (Fig. 4B).Similarly, after stratification between MASLD status and CDAI based on the covariates described above, MASLD status was negatively associated with CDAI among participants who were female, non-Hispanic white, had more than a high school degree, without diabetes, and those with hypertension.However, there may have been an interaction when stratified by race, indicating that this result was confounded by race (Fig. 4A).After stratifying LSM and CDAI based on the covariates described above, the p-values for the trend in the subgroup analyses were essentially > 0.05, and there were several subgroup analyses with interaction effects observed.Therefore, it was speculated that the results of the correlation between LSM and CDAI were not robust (Fig. 4C).

Dose-response relationships between MASLD status, CAP, LSM, and CDAI
Lastly, restricted cubic spline analysis was also employed to analyze the dose-response relationship between MASLD status, CAP, LSM, and CDAI separately (Fig. 5).We found significant nonlinear relationships between participants' MASLD status, CAP, LSM, and CDAI (both P overall and P nonlinear were less than 0.05).MASLD status, CAP, and CDAI exhibited an inverted U-shaped relationship, while LSM and CDAI showed a U-shaped relationship, and the CDAI corresponding to the inflection points of the three were 0.349, 0.699, and 0.174, in that order (Fig. 5A-C).After further stratifying by gender, we found a significant linear relationship between MASLD status, CAP, and CDAI in females (all P nonlinear > 0.05), while a significant nonlinear relationship in males (all P nonlinear < 0.05), with CDAI corresponding to the inflection points in the curves in males being 1.325, 0.985, respectively (Fig. 5D,E).In this study, the relationship between LSM and CDAI, stratified by sex, was significantly linear for males and nonlinear for females, and the CDAI corresponding to the inflection point in the curve for females was 0.548 (P overall < 0.0001, and P nonlinear < 0.0001) (Fig. 5F).Subgroup analysis was further conducted on the relationship between MASLD status (A), CAP (B), LSM (C), and CDAI, respectively, according to gender, age, race, marital status, education level, PIR, BMI, as well as the presence of diabetes and hypertension.In subgroup analysis, "p for interaction" refers to the p-value used to assess whether the interaction between different subgroups is significant.By calculating the p-value for interaction, it can be determined whether there is a significant interaction between different subgroups.If p for interaction < 0.05, it can be concluded that the interaction between different subgroups is significant, meaning that these subgroups have a significant impact on the relationship between variables, and vice versa.MASLD Metabolic dysfunction-associated steatotic liver disease, CAP controlled attenuation parameter, LSM liver stiffness measurement, CDAI composite dietary antioxidant index, PIR family income-to-poverty ratio, BMI body mass index.

Discussion
Our analysis of a cross-sectional study involving 12,286 participants from the NHANES database revealed that higher CDAI levels may be associated with decreased CAP values, particularly in female, younger, non-Hispanic white, unmarried, non-hypertensive, and obese participants, with a robust negative correlation between CDAI and CAP values.The Singapore Chinese Health Study yielded results indicating a correlation between CDAI and a decreased risk of colorectal cancer.This association was particularly notable among females and overweight individuals, highlighting a more pronounced effect in these subgroups 42 .Peroxisome proliferator-activated receptor γ coactivator-1α (PGC1A) is a key regulatory factor in mitochondrial function and can exert influence over lipid metabolism and oxidative stress in the liver and adipose tissue 43 .PGC1A in hepatocytes acts on its effects through estrogen receptor signaling in females and plays an important role in regulating antioxidant enzymes that help mitigate oxidative damage that can arise from diet-induced steatotic liver disease 44 .In our study, the proportion of female MASLD patients was 47.24%, while the proportion of male MASLD patients was 52.76%.
This result also suggests a potential protective role of estrogen against steatotic liver disease.The results of another national study in the Polish adult population showed that higher socioeconomic status was correlated with better lifestyle (such as less smoking) and improved health status (lower prevalence of obesity, hypertension, diabetes, especially among women), as well as dietary habits that involve consuming more dietary antioxidants 45 .We also found similar results, especially with higher CDAI levels observed in the female population with PIR > 3.
NAFLD is linked to metabolic syndromes such as dyslipidemia, T2DM, obesity, and hypertension, which can lead to insulin resistance and adipose tissue dysfunction 46 .The results of our study showed that HDL-C was negatively associated with glucose, HbA1C, uric acid, insulin, BMI, TG, CAP, and waist circumference, which indirectly suggests that dyslipidemia is closely related to metabolic syndromes such as diabetes and obesity.In recent years, NAFLD has been successively renamed MAFLD and MASLD and has attracted much attention in the field of liver disease.The new definition of MASLD retains the restriction on alcohol intake while also introducing the requirement for the presence of at least one of the five cardiometabolic risk factors, which places greater emphasis on the complex relationship between hepatic fat accumulation and metabolic dysfunction and excludes the influence of alcohol, improving the ability of clinicians to recognize individuals at risk for diabetes [11][12][13] .The pathophysiological mechanisms underlying the development of NAFLD are highly complex.Currently, it is widely believed that the "multiple parallel hits" hypothesis, encompassing insulin resistance, lipid accumulation, oxidative stress, endoplasmic reticulum stress, genetic and epigenetic mechanisms, microbial modulation, and environmental factors, are all involved in the development of NAFLD 47 .Sedentary behavior, low physical activity, and poor diet are considered the "triple-hit behavioral phenotype" resulting in the development of NAFLD.Considering the current lack of approved drugs for treating NAFLD, improving dietary structure and increasing physical activity remain important approaches for managing NAFLD 14,48 .
Reactive oxygen species (ROS) can contribute to abnormal lipid metabolism and play a significant role in the occurrence and progression of NAFLD.The imbalance between the generation of ROS and antioxidant defense systems can lead to oxidative stress and cellular tissue damage 49 .Studies have shown that numerous natural products and plant-derived compounds exhibit antioxidant and anti-inflammatory properties, which may have the potential to provide preventive effects against hepatic steatosis in NAFLD 50 .Another cross-sectional study found that patients with lower levels of liver damage, as indicated by liver biopsies, had higher total antioxidant capacity (TAC) in their dietary intake, which also suggests that consuming foods rich in natural antioxidants may play an essential role in mitigating the production of free radicals and alleviating oxidative stress 51 .The CDAI is calculated based on 24-h recalled dietary intake containing six antioxidants and is used to assess the anti-inflammatory properties of the diet, with higher CDAI indicating greater exposure to antioxidants 26,27 .Luu HN et al. 27 evaluated the relationship between CDAI and ten oxidative stress or inflammatory biomarkers, indicating a negative correlation between CDAI and the levels of IL-1β and TNF-α.In this study, we observed a statistically significant difference in another inflammatory marker, Hs-CRP, among different quartiles of CDAI.Hs-CRP levels decreased as CDAI quartile levels increased, indicating that a higher CDAI is associated with antioxidant and anti-inflammatory effects.
We found that vitamin A, vitamin E, carotenoid intake, and CDAI were all negatively correlated with CAP, waist circumference, GGT, and ALP.Vitamin A is involved in the regulation of critical physiological processes including cell proliferation and differentiation, embryonic development, vision, immune function, and carbohydrate and lipid metabolism 52,53 .Vitamin A is involved in bile formation within the liver and is stored in hepatic stellate cells (HSCs).When hepatocytes are damaged, HSCs are activated, leading to vitamin A deficiency, with circulating and hepatic levels of vitamin A declining in the NAFLD disease spectrum 54 .Dietary sources of vitamin A were negatively correlated with NAFLD-related metabolic markers in our study, suggesting the potential of vitamin A for the treatment of NAFLD and metabolic syndrome.Vitamin E is a fat-soluble antioxidant that prevents the overproduction of oxygen free radicals, as well as having regulatory functions involved in inflammatory responses, gene expression, cellular signal transduction, and cell proliferation 55 .Previous clinical studies have demonstrated that vitamin E therapy can improve liver inflammation, hepatic steatosis, and oxidative stress in patients.It can also enhance the liver decompensation period and improve liver transplant-free survival in patients with advanced fibrosis due to NAFLD [56][57][58] .Currently, it is assumed that genetic variants in haptoglobin and fatty acid desaturase 1/2 (FADS1/FADS2) may contribute to the different treatment responses of vitamin E in patients with NAFLD 59 .Considering that vitamin E may improve non-alcoholic steatohepatitis (NASH) symptoms in some nondiabetic patients, the American Association for the Study of Liver Diseases (AASLD) recommends that vitamin E be used in this specific group of individuals 60 .Carotenoids are a class of lipophilic pigments that are primarily present in vegetables and fruits, which cannot be synthesized by humans and must be obtained from dietary intake.Carotenoids have antioxidant, antibacterial, immunomodulatory, and antiinflammatory activities, as well as the potential to reduce markers associated with metabolic syndrome 61 62 .In addition, oral supplementation with vitamin C may also improve liver function and glucose in patients with NAFLD, especially 1000 mg/day, and these findings are consistent with our research results 63 .
Our study didn't reveal any correlation between trace elements zinc and selenium and metabolic-related markers, while another study suggested that reduced serum zinc and selenium levels could potentially serve as risk factors for hepatic fibrosis in NAFLD 64 , and more extensive population-based studies are still needed to validate this conclusion in the future.Although numerous studies have been conducted to explore the link between individual dietary antioxidants and NAFLD, it is important to consider that our diet typically consists of a variety of antioxidants.Therefore, we specifically examined the relationship between the CDAI and NAFLD in our research.The study showed that CDAI was not only negatively correlated with NAFLD-related markers but also negatively correlated with glucose and BMI, and there was a good synergy effect observed among dietary antioxidant components.Studies by Abenavoli L et al. 65 indicate that the Mediterranean diet is a food combination dietary pattern with antioxidant and anti-inflammatory properties that can improve various diseases associated with oxidative metabolism imbalance.Long-term high adherence to the Mediterranean diet is associated with the reduction of liver fat levels and improvements in MetS indicators 66 , and it can also improve and alleviate oxidative stress biomarkers related to NAFLD 67 .Finally, from a Mendelian genetic perspective, dietary antioxidant intake is negatively associated with the occurrence of NAFLD and metabolic-related markers such as blood glucose 68 .There was no significant difference in CDAI among the various MASLD populations in this study, nor was there a significant correlation between CDAI, each dietary antioxidant, and LSM.In another study of ours, we found that with an increase in dietary intake of the antioxidant daidzein from soy, the prevalence of MAFLD and CAP values decreased.This suggests that dietary intake of antioxidants from soy may help reduce liver fat levels, although no significant reduction in LSM values in patients was observed 69 .RCS analysis exhibited a significant linear relationship between LSM and CDAI in males and a non-linear relationship in females after stratification by gender.However, the average LSM value of all participants in the study was 6.0 kPa, which is lower than the upper limit of normal of 6.3 kPa, indicating an overall absence of liver fibrosis among the participants.Therefore, this dose-response relationship cannot accurately reflect the association between CDAI and liver fibrosis.In the future, we need to further investigate the relationship between dietary intake of antioxidants and liver fibrosis.
Our study's strength lies in that we used a complex stratified analysis of a large, nationally representative sample of the population, which enhance the representativeness and reliability of our results.However, this study also has its limitations.Firstly, this is a cross-sectional study, therefore, we cannot conclude whether there is a causal relationship between CDAI and MASLD or CAP, and further validation in prospective cohort studies is needed.Secondly, the CDAI was calculated based on data obtained from the 1st 24-h dietary recall interview.Thus, CDAI may not represent participants' long-term and actual dietary patterns.Fortunately, the reliability of the questionnaire results regarding dietary intake has been extensively validated based on dietary records and biomarkers 70 .Thirdly, in this study, we employed non-invasive VCTE to determine whether participants had hepatic steatosis and liver fibrosis instead of using liver biopsy, which inevitably leads to diagnostic bias in the diagnosis of MASLD.Finally, we attempted to adjust for various relevant confounding variables, but still could not completely exclude the possibility that potential residual confounders could lead to biased conclusions.In conclusion, in the future, we will need more randomized controlled trials to determine the phenotype impact of CDAI on MASLD.

Conclusions
In summary, we observed that higher CDAI may be correlated with decreased CAP values, especially in females, suggesting that intake of complex dietary antioxidants may ameliorate hepatic steatosis and reduce the incidence of MASLD.Therefore, promoting a dietary pattern rich in antioxidants may be an appropriate strategy to alleviate the burden and prevalence of MASLD disease.However, the correlation between CDAI and liver fibrosis markers is not strong in this study, and further research is needed to explore the treatment of liver fibrosis in patients with MASLD.

Figure 2 .
Figure 2. Heatmap of correlation analysis between dietary antioxidant intake and CDAI with anthropometric measures and blood biochemical parameters illustrates statistically significant correlation results among these indicators.The heatmap only displays the results of significant correlations between various indicators.CDAI composite dietary antioxidant index, HDL-C high-density lipoprotein cholesterol, TG triglycerides, TC total cholesterol, LDL-C low-density lipoprotein cholesterol, HbA1c glycosylated hemoglobin, CAP controlled attenuation parameter, LSM liver stiffness measurement, WC waist circumference, BMI body mass index, Se selenium, Vit_C vitamin C, Vit_A vitamin A, Vit_E vitamin E, ALP alkaline phosphatase, GGT gamma glutamyl transferase, ALT alanine aminotransferase, AST aspartate aminotransferase, LDH lactate dehydrogenase.

Figure 3 .
Figure 3. Violin plots comparing the differences between CAP, LSM, and CDAI among different categories of MASLD, respectively.In violin plots, the differences between CAP (A), LSM (B), and CDAI (C) in different MASLD classifications were compared, separately.The Kruskal-Wallis test was used to compare multiple independent continuous variables, with "ns" indicating no statistical significance and "***" indicating p < 0.001.CAP controlled attenuation parameter, LSM liver stiffness measurement, CDAI composite dietary antioxidant index, MASLD Metabolic dysfunction-associated steatotic liver disease, MetALD MASLD and greater alcohol consumption.

Figure 4 .
Figure 4. Subgroup analysis was further conducted on the relationship between MASLD status (A), CAP (B), LSM (C), and CDAI, respectively, according to gender, age, race, marital status, education level, PIR, BMI, as well as the presence of diabetes and hypertension.In subgroup analysis, "p for interaction" refers to the p-value used to assess whether the interaction between different subgroups is significant.By calculating the p-value for interaction, it can be determined whether there is a significant interaction between different subgroups.If p for interaction < 0.05, it can be concluded that the interaction between different subgroups is significant, meaning that these subgroups have a significant impact on the relationship between variables, and vice versa.MASLD Metabolic dysfunction-associated steatotic liver disease, CAP controlled attenuation parameter, LSM liver stiffness measurement, CDAI composite dietary antioxidant index, PIR family income-to-poverty ratio, BMI body mass index.

Figure 5 .
Figure 5.RCS analysis was used to analyze the dose-response relationships between MASLD status, CAP, LSM, and CDAI, respectively.RCS analysis using weighted multiple regression models was used to investigate the relationship between MASLD status (A), CAP (B), LSM (C), and CDAI, separately.After stratification by gender, the relationships between MASLD status (D), CAP (E), LSM (F), and CDAI were further analyzed.In RCS analysis, P overall and P nonlinear represent the significance of the overall model and the non-linear component, respectively.When both P overall and P nonlinear are less than 0.05, it indicates that both the overall model effects and the non-linear component are statistically significant, suggesting that the relationship between the considered independent variables and the dependent variable in the model is statistically significant and exhibits a non-linear relationship.RCS restricted cubic spline, CAP controlled attenuation parameter, LSM liver stiffness measurement, CDAI composite dietary antioxidant index, MASLD Metabolic dysfunctionassociated steatotic liver disease.

Table 1 .
Baseline characteristics of participants by quartiles of CDAI (N = 12,286).Mean (± SD) of continuous variables: p-values calculated by weighted linear regression.Percentages for categorical variables: p-values calculated by weighted Wilcoxon rank sum test.Statistical significance is defined as p < 0.05.CDAI composite dietary antioxidant index, PIR family income-to-poverty ratio, BMI body mass index, LSM liver stiffness measurement, CAP controlled attenuation parameter, DM diabetes mellitus, preDM prediabetes, MASLD Metabolic dysfunction-associated steatotic liver disease, MetALD MASLD and greater alcohol consumption, SLD steatotic liver disease.alignwith the guidelines and regulations established by the relevant authorities, institutions, and professional bodies to ensure the validity, integrity, and ethical conduct of the study.

Table 3 .
Relationship between CAP, LSM, MASLD status and CDAI in a multiple regression model.Crude Model: without adjusting for any covariates.Model I: adjusted for age, gender, and ethnicity.Model II: adjusted for the variables of age, gender, ethnicity, marital status, education level, diabetes mellitus, hypertension, PIR, waist circumference, BMI, smoking, and alcohol use.MASLD Metabolic dysfunction-associated steatotic liver disease, CDAI composite dietary antioxidant index, Q quartile, CAP controlled attenuation parameter, LSM liver stiffness measurement, PIR family income-to-poverty ratio, BMI body mass index, CI confidence intervals.